Patient Health Questionnaire (PHQ-9)

If you have been advised by the surgery to submit a Patient Health Questionnaire (PHQ-9) please use this form.

Patient Health Questionnaire (PHQ-9)

Patient Health Questionnaire (PHQ-9)

BMI

Smoking Status

Do you currently smoke?
Have you smoked in the past?
How many cigarettes did you smoke in a day?
How many cigarettes do you smoke in a day?
Would you like to give up smoking?

Smoking cessation support is available at the practice, through local pharmacies and via the NHS website.

If you would like to consider giving up smoking in future, please contact the surgery who will be able to offer support.

Review

Over the last 2 weeks, how often have you been bothered by any of the following problems:

Little interest or pleasure in doing things: *
Feeling down, depressed, or hopeless: *
Trouble falling or staying asleep, or sleeping too much: *
Feeling tired or having little energy: *
Poor appetite or overeating: *
Feeling bad about yourself — or that you are a failure or have let yourself or your family down: *
Trouble concentrating on things, such as reading the newspaper or watching television: *
Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual: *
Thoughts that you would be better off dead or of hurting yourself in some way: *
Please answer the following questions using the following scale: 0 - never avoid it, 2- slightly avoid it, 4 - definitely avoid it, 6 - markedly avoid it, 8 - always avoid it
Social situations due to a fear of being embarrassed or making a fool of myself *
Certain situations because of a fear of having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting or dizziness) *
Certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces, driving or flying) *
Radio Buttons
*
Radio Buttons